05-001 (4) APPLICANT /CONTACT PERSON MASONIC HEALTH SYSTEM OF MASS
ADDRESS/PHONE 88 MASONIC HOME RD (508) 434 -2262
TX LOCATION 222 RIVER RD
OS PARCEL 001 00i ` bI
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING F FILLED OUT
ee ai
Building Permit Filled out
Fee Paid
Typeof Construction: ZPA
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FOLLOWING ACT3ON HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRE�fTED: 3 51-0 — F� RC { fJ i ( - rAGU :- �
Approved Additional permits required (see below)
.356 0- to
PLANNING BOARD PERMIT REQUIRED UNDER: §
Sid f` ff
Intermediate Project: Site Plan AND /OR _ dal Permit with Site Plan
Major Project: Site Plan AND /OR Special Permit with Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:--- V pme Dan PQ %iF L C I OTAtrz—
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Sign a of Building icial Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact the Office of
Planning & Development for more information.
C�[ QWE
Fite No. ,
ZONING PERMITAPPLICATION 6910= 2010 k�
Please type or print all information and return this ri to the Build
Inspector's Office with the $15, filing fee (check or mone orol #tab r the
11 City of Northampton �� - "" '��'� i 6
1. Name of Applicant: J - o ci e is bi 4 V P /' IaSOMC aeO h � JS7Vf AA
Address: 2?Q f�i J-e r KJ . , 3 Telephone 3 'Sg 24 5 6-TI 2-
2. Owner Of Property: N' C r & S re M SSA Ck
A � 1!50:f
Address: M AS4 t U G Telephone: 5bS ±
fSc.Ul�e f'
3. Status of Applicant: Owner Contract Purchaser Lessee Other (explain
4. Job Location:
Parcel id: Zoning Map# Parcel# District(s):
In Elm Street District In Central Business District
(TO BE FILLED IN BY THE MM BUILDING DEPARTMENT
5. Existing Use of Structure /Property: lyE L51 /V Q i'�t�c:. M e__
6. Description of Proposed Use /Work /Project /Occupation: (Use additional sheets if necessary):
k'p-19 etm&N �- Ary /I om �. u,VV +i� e rna 110 JSt✓
6 W4
7. Attached Plans: Sketch Plan Site Plan Engineered /Surveyed Plans
8. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW X YES IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and /or Document #
9.Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES X
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained X Obtained , date issued:
(Form Continues On Other Side)
W:\Docunmts\ FORMS \original \Building- Inspector\Zoning- Permit - Application- passive.doc 814/2004
10. Do any signs exist on the property? /1t1 ,, YES x NO
IF YES, describe size, type and location: (4 `f 4 m i iy' (f t-d Aj C *6e p{'r7p e coo
( hj d, SMA ll Gtfea- of V i Loe( QI oN8 (S GL ,Sigh N'al'ntN fl" e." AC4,
e- S fJ Wa: &(eS gZ` 'e base 61 is D is made, cs a—
Vi ta s �- - 0y" ®sc ' /h ��� - ( v;_
Are there any proposed Changes to or additions of signs intended for the property? YES NO X_
IF YES, describe size, type and location:
11. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common
plan of development that will disturb over 1 acre? YES_ NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
12. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION
This column reserved
for use by the Building
.Departmen
EXISTING PROPOSED REQUIRED BY
ZONING
Lot Size
o co (o 60 5
Frontage
Setbacks Front
Side L: R: L: R. L: R:
Rear
Building Height
Building Square Footage _ _
5 �� 006 ,5 3, 000 t -7
% Open Space: (lot area
minus building ft paved
parkin
# of Parking Spaces
/ 0 C)
# of Loading Docks `
Fill:
volume Et location
13. Certification: I hereby certify that the information contained herein is true and accurate to the best of
my knowledge.
c
Date: Applicant's Signature �..
s
NOTE: Is uance of a zoning permit does not relieve pplicant's burden to comply wi all oning
requirements and obtain all required permits from the Board of Health, Conserva Commission,
Historic and Architectural Boards, Department of Public Works and other applicable permit granting
authorities.
W:1 Docutnent s\FORM3b rigina l\Building- Inspector\Zoning- Permit - Application- passive.doc 8/4/2004